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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198001060
Report Date: 08/23/2024
Date Signed: 08/23/2024 10:09:17 AM

Document Has Been Signed on 08/23/2024 10:09 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:KIDS KLUB PASADENAFACILITY NUMBER:
198001060
ADMINISTRATOR/
DIRECTOR:
VIVIAN LEIS-CHANGFACILITY TYPE:
850
ADDRESS:380 SO. RAYMOND STREETTELEPHONE:
(626) 795-2501
CITY:PASADENASTATE: CAZIP CODE:
91105
CAPACITY: 195TOTAL ENROLLED CHILDREN: 195CENSUS: 0DATE:
08/23/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Crystal Ramirez TIME VISIT/
INSPECTION COMPLETED:
10:30 AM
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On 08/23/24, at 08:30 am ,Licensing Program Analyst (LPA) Shushanik Safaryan conducted an unannounced Case Management inspection for the purpose for the following up on an unusual incident report received by the Department . Upon arrival at 08:30 am, LPA met with Facility Representative Krystal Ramirez , to whom the purpose of the inspection was explained. Tour of the facility was provided. There were no children present during the inspection. Facility had a Fall Prep Day for the first day of school which was scheduled to be 08/26/24.

On 07/29/24, 07/23/24, 04/23/24 an unusual incident reports were submitted to the Department regarding children sustaining an injury on the facility grounds that need a medical treatment .

On 07/29/24 Facility reported child #2 approached staff #1 and indicated that child#1 had a seed in his ear . After examination teacher confirmed observing tree seed in child #2 left ear. LPA examined the area , facility had a big tree in the yard over the wood chip area with the little seeds . Per director maintenance was asked to clean more often to avoid future incidents . Facility reminded children


regarding safety and safety of their friends when playing .

On 07/23/24 Facility reported child #3 was playing outside and lost her balance on the chair when was leaning and bumped her left side of the forehead on the tree stump. LPA observed the wood chip area next to the cottage where the incident took place . LPA did not observe tree stump in that area . Per Director tree stump was removed after the incident to the sand area to avoid future incidents .

On 04/23/24 Facility reported child #4 was chasing ball outside in the soft yard when fell forward causing her to bump her nose on the brick step . LPA observed the area where the incident took place and did not observe any obstructions .

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SUPERVISORS NAME: Brandi VanOosten
LICENSING EVALUATOR NAME: Shushanik Safaryan
LICENSING EVALUATOR SIGNATURE: DATE: 08/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/23/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: KIDS KLUB PASADENA
FACILITY NUMBER: 198001060
VISIT DATE: 08/23/2024
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During the visit LPA obtained copies of sign in/out sheets for all 3 incidents .Ratio and staffing were in accordance with Title 22 Code of Regulations at the time of the incidents. LPA interviewed staff , no children were present during the visit.

At this time, there is not a preponderance of evidence that shows that the facility was in violation with Title 22 Regulations when these incidents occurred. Therefore, there are no deficiencies being cited.


The Notice of Site Visit (LIC 9213) – must remain posted for 30 days during the hours of operation after each site visit by a licensing representative.

Exit interview conducted with the Director Krystal Ramirez and Copy of Report provided.

END OF REPORT

SUPERVISORS NAME: Brandi VanOosten
LICENSING EVALUATOR NAME: Shushanik Safaryan
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2024
LIC809 (FAS) - (06/04)
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